Contact Information
Name :
_____________________________________________________________________________________________
(last)
(first)
(middle)
Company/Organization : ______________________________________
Title : _________________________________
Address :
____________________________________________________________________________________________
_____________________________________________________________________________________________________
Phone :
______________________________________________________________________________________________
(daytime)
(mobile/evening)
E-mail :
______________________________________________________
Class Preference
Please check the class you will prefer to attend.
October 15 - 19, 2007 (San Jose)
How did you hear about us ?
_________________________________________________________________
Registration Fee
Please write a check or money order for
$2,995 payable to "Harker Systems"
(unless paying by credit card),
and send it with this enrollment form to:
Harker Systems
4182 Pleasant Hill Rd
Lincoln, CA 95648
Payment by Credit card:
Card number: ___________________________________
Expiration: ________________
CID/CVV2 number:_____________
(CID/CVV2 number is the 4 digit number on top of AMEX or 3 digit
number at the end of signature panel of
Visa/Master Card/Discover)
Card type (circle one): Visa Mastercard
American Express
Name on the Credit card:
____________________________________
Signature: ______________________ Date: ________________
Credit Card Billing address:
____________________________________
___________________________________________________________
If paying by credit card, please contact us for
instructions
Please do notify us via email when sending the form.
Signature_________________________________________
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